REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT AUGUST 2011 This publication was produced for review by the United States Agency for International Development. It was prepared by Benson Barh, Selam Kebrom, Cecelia Morris, Mbuyi Mutala, and Bruce Grogan (Team Leader) through the Global Health Technical Assistance Project.
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REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
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REBUILDING BASIC HEALTH
SERVICES (RBHS): YEAR 2
ASSESSMENT
AUGUST 2011
This publication was produced for review by the United States Agency for International
Development. It was prepared by Benson Barh, Selam Kebrom, Cecelia Morris, Mbuyi Mutala,
and Bruce Grogan (Team Leader) through the Global Health Technical Assistance Project.
REBUILDING BASIC HEALTH
SERVICES (RBHS): YEAR 2
ASSESSMENT
DISCLAIMER
The authors‘ views expressed in this publication do not necessarily reflect the views of the
United States Agency for International Development or the United States Government.
This document (Report No. 11-01-513) is available in printed or online versions. Online
documents can be located in the GH Tech website library at http://resources.ghtechproject.net.
Documents are also made available through the Development Experience Clearinghouse
(http://dec.usaid.gov). Additional information can be obtained from:
JHUCCP Johns Hopkins University Center for Communications Programs
iv REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
JSI John Snow Inc.
LQAS Low Quality Assurance Sample
M&E Monitoring and evaluation
MOHSW Ministry of Health and Social Welfare
MOU Memorandum of understanding
MSH Management Sciences for Health
MTI Medical Teams International
NGO Non-governmental organization
NHSWP 2011–2021 National Health and Social Welfare Plan
OIC Officer in charge
PA Physician‘s assistant
PCT Program coordination team
PBC Performance-based contract
PBF Performance-based financing
PPP Public-private partnership
RBHS Rebuilding Basic Health Services
RN Registered nurse
SBCC Social and behavior change communication
SOPs Standard operating procedures
TB Tuberculosis
TNIMA Tubman National Institute for Medical Arts
TPM Team planning meeting
TTM Trained traditional midwife
WASH Water, sanitation, and hygiene
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT v
EXECUTIVE SUMMARY
The purpose of this non-quantitative assessment was to review the performance and the
progress of the five-year Rebuilding Basic Health Services (RBHS) project, which is now at its
mid-point, and assess the appropriateness of the project design. The assessment identified
factors enabling or impeding the effective implementation of different components of the
project, with emphasis placed on the performance-based contracting (PBC) component. The
assessment advised the U.S. Agency for International Development (USAID)/Liberia on any
necessary redirection of strategies or priorities that could modify the approaches currently used
and/or provide suggestions on any possible expansion of the project. More specifically, the
assessment team evaluated the progress made in achieving the three intermediate results of the
RBHS Project. The methodology for assessment included interviews, data collection, and review
of resources.
Eight years after emerging from two prolonged and devastating civil wars, Liberia is beginning to
make slow but measurable progress on a range of economic and social outcomes. The impact of
the conflicts on the health sector was as severe as on any other, and included loss of staff,
destruction of infrastructure, disruption of health programs, and diminishment of resources,
along with the resultant increased dependency on international donors. The cornerstone of the
Government of Liberia‘s (GOL) post-conflict national health policy, as formulated and endorsed
in 2007, has been the rollout of a basic package of health services (BPHS) to all citizens. This
BPHS is composed of a number of evidence-based, affordable health interventions designed to
reach the population through a network of health clinics, health centers, and first-level referral
hospitals across Liberia.
The RBHS project is the United States Government‘s flagship bilateral health project to support
the Ministry of Health and Social Welfare (MOHSW). The RBHS project is a $62 million-five-
year cooperative agreement (2008–2013) with John Snow Inc. (JSI), Research and Training, in
collaboration with JHPIEGO, Johns Hopkins University Center for Communication Programs
(JHUCCP), and Management Sciences for Health (MSH). The project supports the following
USAID strategic objectives:
Increased access to basic health services through improved provision of quality health
services and adoption of positive health behaviors; increased quality of health services
through improving infrastructure, health workforce and systems performance by enhancing
capacity to plan, manage, and monitor a decentralized health system; and youth informed
and networked on reproductive health.
This evaluation concluded that the RBHS project is making significant progress toward achieving
its goals and objectives. Specifically, the strengths of the project include:
1. The introduction of a data-driven culture
2. Evidence-based service delivery and supportive supervision
3. Some improvement in quality care
4. Timely provision of supplies and services
5. An active community volunteer network
6. A strong in-service training program.
vi REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
The weaknesses of the project include:
1. Insufficient progress in building the capacity of the county health and social welfare teams
(CHSWT) and mid-level management in the MOHSW
2. Lack of coherent strategy for measureable progress
3. Insufficient attention to infrastructure requirements and health care financing as per the
original project description
During the final two years of the project, RBHS will shift its focus away from service delivery
toward a concentration on building the capacity of the MOHSW, including the CHSWTs,
facilitating an effective management transition of the PBC program, and supporting the transition
toward decentralizing MOHSW management .
The overarching recommendations of the assessment team are that RBHS: 1) continue to
support the MOHSW in the development of policies, procedures, and guidelines required for
both a successful transition toward decentralization and MOHSW management of PBCs, and 2)
develop the capacity of the CHSWTs to effectively supervise PBCs. It is the team‘s
recommendation that RBHS employ a mentoring, or counterpart, approach to building the
capacity of the senior, mid-level, and county-level members of the MOHSW. The team also
recommends that the focus on health outcomes be pursued through a vision of health service
delivery that stresses the importance of systems-thinking, which links all stakeholders from the
facility through the ministry level. Another specific recommendation includes the need for an
integrated health education program that employs all available and appropriate technology.
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 1
I. BACKGROUND
PURPOSE OF ASSESSMENT
The purpose of this assessment was to review the performance and the progress of the five-
year RBHS project, which is now at its mid-point, and assess the appropriateness of the project
design relative to the pending transition of responsibility to MOHSW. The assessment identified
factors enabling or impeding effective implementation of different components of the project,
particularly as they relate to the transition. Transition entails the gradual transfer or hand-over
of the RBHS project management responsibilities of sub-partners from JSI to the central
MOHSW for future ownership and management, as per the agreement between the GOL and
USAID. It is understood that during the last two years of the project, RBHS will gradually cease
providing health services directly and will instead provide support to central MOHSW for
management of contracts for service delivery and CHSWT support. This support, in the form of
technical and managerial assistance, will focus on skill sets to manage implementing partners.
This major shift in the project‘s course is referred to as the transition throughout this report.
The objective of this evaluation was to advise USAID/Liberia on any necessary redirection of
strategies or priorities that could modify approaches that are currently being used and/or
provide suggestions on any possible expansion of the project. More specifically, the evaluation
team was expected to assess the progress made in achieving the three intermediate results of
RBHS:
1. Increased access to basic health services through improved provision of quality health
services and adoption of positive health behaviors
2. Increased quality of health services through improving infrastructure, and health workforce
and systems performance by enhancing the capacity to plan, manage, and monitor a
decentralized health system
3. Youth informed and networked on reproductive health
The review included a cursory look at the progress made in relation to the operation of the six
key principles in the program description: 1) participation; 2) partnership; 3) capacity building; 4)
gender sensitivity; 5) youth focus; and 6) data driven.
Additionally, the assessment team was to identify the lessons learned, provide suggestions for
the future direction of Liberia‘s health initiatives to ensure a comprehensive and consistent
maternal and child health strategy, and determine new areas for technical support relating to the
upcoming transition.
METHODOLOGY
This is a qualitative evaluation designed to collect and analyze key stakeholders‘ opinions,
perceptions, and experiences with the RBHS Project. The quantitative point of departure for
this assessment was RBHS-generated data and other stakeholder information obtained from
MOHSW, the Clinton Health Access Initiative (CHAI), and the World Bank (e.g., Health
Management Information System [HMIS], Comprehensive Food Security National Survey
(CFSNS), Expanded Program on Immunization [EPI] coverage, Low Quality Assurance Sample
[LQAS], etc.). The RBHS Semi-Annual Report presented quantitative and self-reported data
regarding the project‘s performance and progress toward meeting its goals and objectives. The
RBHS data were drawn from the HMIS and crosschecked for accuracy. Other sources of data,
though informative, were less useful. The Food Security and Nutritional Status could not be
2 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
directly correlated with the HMIS and RBHS data, given the survey nature of the data collection.
The EPI coverage data were last collected in 2009 and are outdated. And the LQAS program
recently released a draft report that is being studied by RBHS in order to identify and explain
data results that conflict with the RBHS data. RBHS will report this to USAID upon completion
of the review.
The information provided by other stakeholders ranged from assessments by the World Bank of
the PBC model1 to descriptive data collected during interviews with the MOHSW, United
Nations, Global Fund, CHAI, and the Carter Center, during which the various steps the
MOHSW is taking to develop revised policies, procedures, and regulations, as well as the efforts
being made to collect real time service delivery data and annual accreditation data in an
MOHSW partnership with the CHAI, were identified. The methodology used for collecting and
analyzing the required information included: team planning meeting (TPM), document review,
interviews with key stakeholders,2 site visits to RBHS health facilities, and direct observation by
team members.
This assessment fulfills conditions set forth by USAID‘s Evaluation Policy, which requires that
each operating unit conduct at least one performance evaluation for each large project. In line
with the policy, the evaluation team was composed of members with relevant subject matter
expertise including program design, monitoring and evaluation (M&E), policy development,
community health education, social and behavior change communication, community
mobilization, human capacity building and training, nursing, midwifery, antenatal care (ANC),
health system management and training. The inclusion of two Liberian health professionals also
afforded an important socio-political context upon which to base findings. This study also
supports USAID Forward‘s procurement reform by providing a basis from which to transfer the
responsibility of health service delivery to the host government in a manner that minimizes the
potential for diminishing quality of service.
LIBERIA HEALTH SECTOR
Eight years after emerging from two prolonged and devastating civil wars, Liberia is beginning to
make slow but measurable progress on a range of economic and social outcomes. An illustrative
example of this slow but discernable progress is the strong commitment by the GOL through
the MOHSW to rebuild and reform its health system with the support of bilateral and
multilateral assistance. They have done so by rolling out a basic package of health services
intervention designed to reach all Liberians through the existing network of health centers,
clinics, and first-level referral hospitals all over Liberia. Early indications of progress suggest that
there have already been improvements in some important health outcomes.
Infant and child mortality rates have reduced since earlier in the decade and now compare
favorably with regional rates, as shown in Table 1 below.
1 World Bank, July 2011. 2 Key stakeholders included USAID/Liberia staff, MOHSW leadership, CHSWTs, health facility staff, and
other donors/international agencies.
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 3
Table 1. Key Health Indicators for Liberia (Source: RBHS Program Description)
Health Indicator Liberia Regional
Average
Global
Average
Infant Mortality Rate (Department of
Human Services [DHS] 2007) 72 97 47
Under-5 Mortality Rate (DHS 2007) 111 169 68
Maternal Mortality Ratio (DHS, 2007) 994 1100 400
The MOHSW has emerged as one of the strongest and most effective government entities in
Liberia. Over the past four years, the MOHSW has demonstrated strong leadership and vision,
developed a sound national health policy and plan, and collaborated effectively with its partners.
While the health sector will require substantial external assistance for years to come, it is clear
that the MOHSW is taking the lead on setting national policies, strategies, and plans. In July of
2011, the ministry released a new National Health and Social Welfare Plan (NHSWP 2011–
2021) consistent with the GOL‘s Poverty Reduction Strategy. The goal of this NHSWP 2011–21
is to improve the health and social welfare status of the population of Liberia on an equitable
basis. As per the plan:
Sustained leadership, stakeholder commitment, resources and effort are needed to achieve
this by: 1) increasing access to and utilization of a comprehensive package of quality health
and social welfare services of proven effectiveness, delivered close to the community,
endowed with the necessary resources, and supported by effective systems; 2) making
health and social welfare services more responsive to people’s needs, demands, and
expectations by transferring management and decision-making to lower administration
levels; and 3) making health care and social protection available to all people in Liberia,
regardless of their position in society, and at a cost that is affordable to the Country.”
The NHSWP 2011–21 expanded the BPHS into the Essential Package of Health Services (EPHS)
to include eight additional areas:
1. Environmental/occupational health
2. Neglected tropical diseases
3. Non-communicable diseases
4. School health services
5. Prison health services
6. Emergency health
7. Mental health
8. Eye care
The EPHS is an approach to health planning in post-conflict developing countries that aims to
concentrate available resources on interventions that promote cost-effective and efficient ways
of improving service delivery.
While before the war the government was the main provider of health care—next to a number
of faith-based organizations (FBOs)—during and after the war, international non-governmental
organizations (INGOs) became main providers in a health system that was in disarray. Against a
backdrop of governmental policy to decentralize, it is the MOHSW‘s vision that the CHSWTs
will be responsible for deciding whether to continue contracting out for services or to deliver
4 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
these services themselves. This is the long-term vision, anticipated to take at least 10 years. In
the near term, however, the MOHSW envisions that INGOs and local non-government
organizations (NGOs) will continue to play an important role in assisting the CHSWTs in taking
up this responsibility until the time when the CHSWT‘s have the capacity to implement
themselves—if they so choose. The transition of management responsibility, including central
contracting for the PBC‘s to the MOHSW, is a short-term solution. Eventually, the CHSWT‘s
will have contracting authority.
All donors and implementing partners use the same service delivery approach in Liberia: the
BPHS (and now EPHS). There are, however, alternative models for funding this approach: a
purchaser-provider model and direct government provision. The ―purchaser-provider‖ models
are governed by contracts between fund holder and implementing agency. In the present case,
the fund holder is the MOHSW with funding from the Pool Fund or from other donors. The
present ―providers‖ are NGOs, except in Bomi County where they are not using NGOs as
implementing partners but rather provide services through the CHSWT. In the future,
they may be NGOs or the CHSWT themselves.
The majority of present contracts are performance-based. RBHS (USAID Fund) and Pool Fund
are similar models, though slightly different. RBHS contracts NGOs to support health service
delivery in a number of counties. From the start this scheme has used PBC as the
implementation vehicle. RBHS has been successful in creating detailed operational procedures
and guidelines. In the RBHS model, targets are negotiated with the INGOs and set by RBHS for
each contract, which includes several health facilities in a county. Contracts do not have
countywide coverage. Performance is judged by monitoring and evaluating the implementing
partners‘ previously agreed upon administrative indicators and service indicators, all of which
are consistent with performance-based contracting.
The Pool Fund was established within the MOHSW in 2009, mainly with funds from the United
Kingdom Department for International Development (DFID) and Irish Aid, to support health
service delivery. It contracted Bomi CHSWT to provide health care in 20 health facilities as a
pilot on ‗contracting in.‘ By March 2010, the Pool Fund also contracted four INGOs to provide
BPHS service delivery to 87 health facilities in six counties. All INGOs partnered with a national
NGO. The MOHSW intended these contracts to be PBCs, but they didn‘t set up mechanisms to
actually assess performance, nor did they pay bonuses during the first year. The Pool Fund Bomi
experience is using the CHSWT to provide health care, whereas the RBHS model contracts
with INGOs to implement the program. Since the geographic coverage of the Pool Fund differs
from that of RBHS, there is no overlap in coverage areas. However, both employ the same data
collection and information systems, as well as the same organizational structure.
The MOHSW‘s decision to assume the RBHS scheme to manage service delivery for PBCs by
June of 2012 reflects its commitment to assume management responsibility for performance-
based financing (PBF). This will more than double the MOHSW‘s direct involvement in PBC,
hence meeting the need for good institutional arrangements, harmonized approaches between
the different PBC schemes, and an operational plan that is widely understood by all
stakeholders.
A recent joint RBHS and World Bank assessment of the Liberian experience with PBCs
concluded that they are well functioning, have produced detailed procedures, function with
flexibility, and are effective at building the capacity of their implementing partners.
However, the report found that there were some significant gaps: 1) there is a large need to
build capacity at the county and central levels of the MOHSW; 2) there is a need for a formal
agreement, possibly a memorandum of understanding (MOU), between the central and county
entities; and 3) there is also a technical gap when it comes to supervising/mentoring the
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 5
performance of health service providers in the districts, in addition to requisite managerial and
technical capacities lacking at the CHSWT level.3
Before the implementation of the PBC models, the MOHSW established a Program
Coordination Team (PCT) to coordinate partners and resources for implementing the NHSWP
2011–2021. The PCT consists of the four deputy ministers supported by technical experts, and
is led by the chief medical officer/deputy minister of health services. The PCT can and should
play a key role in addressing PBC-related needs. The Policy on Contracting foresaw a
comprehensive system for M&E of the NGO contracts to be established within the MOHSW,
which would ensure that results met internationally agreed upon standards of financial
management.
Additionally, the MOHSW set up a PBC steering committee consisting of representatives from
MOHSW departments and other stakeholders. More recent was the appointment by the
MOHSW of a PBC focal point, under the Health Financing Department. Additional activities are
under way within the MOHSW to develop—with RBHS support—a wide range of requisite
policies, guidelines, and procedures, including human-resource–related requirements and system
revisions, infrastructure guidelines, and the development of an operational manual for use in
PBC management.
Under the NHSWP 2011–2021, the MOHSW has committed to establishing appropriate
structures (Program Management Unit, PBF Technical Team, PBF Steering Committee) to
oversee PBF, improve communication with partners, strengthen existing systems of contract
M&E, improve data verification processes, and establish transparent incentive systems. But at
present, the management of the Pool Fund claimed that it is not prepared to assume complete
responsibility for PBC program implementation.4 There is a limited support infrastructure of
policies, procedures, operational guidelines, and human resources in place. Although many of
these are under development (e.g., human resources, financial management, operations manual
for managing and implementing PBCs), they have not been approved for use as of yet.
Additionally, the staff capability to manage the contracts is limited, and there are still significant
training needs associated with financial management.
Although PBCs will be managed from the central level, supervisory responsibilities will reside
with the relevant CHSWT. The long-term vision of the MOHSW is that the responsibility for
managing performance-based partnerships will be shifted to the CHSWTs once administrative
and evaluation processes have been developed. There is no specific timetable established for this
devolution. At present, there are administrative, technical competency, and human-resource
constraints on MOHSW‘s present ability to assume responsibility for PBF, and therefore they
transfer part of that responsibility to the CHSWTs for oversight of the PBC agreements.
RBHS PROJECT OVERVIEW
The RBHS project is the U.S. Government‘s flagship health bilateral project in support of the
MOHSW. The $62 million project, funded by USAID, is a partnership among JSI Research and
Training, Jhpiego, JHUCCP, and MSH. The project is active in select districts in Bomi, Grand
Cape Mount, Lofa, Bong, Nimba, River Gee, and Monsterrado counties
The RBHS project has specific responsibilities in the areas of maternal and child health, family
planning/reproductive health, malaria, human immunodeficiency virus
3 See Appendix C for the MOHSW Liberia PBF Assessment Report, Final Draft, June 2011. 4 Interview with Esther Mwanveza, Program Manager of the Pool Fund, July 2011.
6 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
(HIV), and water and sanitation, with the focus on: strengthening and extending service delivery
through performance-based contracts to NGO partners; strengthening Liberia‘s health system in
human resource management, infrastructure, policy development, M&E, disease prevention;
promotion of health behavior change communication; and community mobilization.
Implementation of RBHS is over a five-year period, 2008–2013, and is guided by a three-pronged
strategic approach:
1. Strengthening and extending service delivery through performance-based grants to NGO
partners
2. Strengthening Liberia‘s health system in the areas of human resource management,
infrastructure, policy development, and M&E
3. Preventing disease and promoting more healthful behaviors through behavior change,
communication, and community mobilization
The RBHS project is implemented to achieve the following results:
Increased utilization and coverage of priority health services, especially maternal, neonatal,
child, and family planning/reproductive health
Expanded availability of and access to services, including at community level (e.g., case
management of childhood infections, family planning)
Improved quality of health services, including improved health worker performance
Increased adoption of healthful behaviors by community members
Strengthened training institutions for mid-level health care providers
Strengthened health systems, especially in the areas of health management information
systems, M&E, and drug management
Increased technical and management capacity of the MOHSW at central and county levels
Improved health infrastructure
PROJECT STATUS
RBHS is overseeing the delivery of the BPHS at 112 facilities and their surrounding communities
in seven counties through five PBCs with four NGO partners—and a grant to a fifth NGO
partner. RBHS continues to document improvements through a range of important indicators,
especially those related to maternal and reproductive health, and malaria. In terms of
management and administration, it appears to the assessment team that RBHS is responding
appropriately to the Liberian situation with flexibility and consistency by effectively using the
capabilities of partners and supervising implementing partners; conducting joint supervision of
health care delivery; introducing a data driven culture in the health system that is likely to
enhance opportunities for good planning and decision-making; and providing capacity building
opportunities such as pre-service and in-service training of health workers.
According to RBHS5, systems strengthening activities have continued to improve both pre-
service and in-service training, supported rollout of HMIS, and made foundational contributions
to the NHSWP 2011–2021. Behavior change communication (BCC) activities have included a
national insecticide-treated net (ITN) campaign, facility- and community-level activities, and
capacity building of national staff. RBHS also provides ongoing support to MOHSW efforts to
implement PBF, including in those areas that RBHS currently supports. In many of its system
5 See Appendix H for detailed reporting on all indicators.
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 7
strengthening efforts, RBHS has both provided technical expertise and attempted to build
capacity at both central and county levels.
Through this collaborative approach, RBHS reported the following achievements in the most
recent semi-annual report to USAID (March of 2011). The team observed that there were some
disagreements regarding specific numbers associated with some indicators. The team heard
some disagreements at the final out-briefing for the MOHSW, but the consensus is that the
results are still significant and positive. These reported results include:
All 112 RBHS—supported health facilities providing BPHS included in the MOHSW‘s 2011
accreditation surveys met national accreditation standards (score: 100%) with an average
score of 88%. The top two nationally scoring NGOs were RBHS partners Medical Teams
International (MTI) with 92% and Africare with 91%.
66% increase in facility-based deliveries.
164% increase in couple-years of family planning protection.
69% increase in pregnant women receiving a second dose of intermittent preventive
treatment of malaria (IPT2).
Treated 112,750 children for malaria, averting an estimated 2,255 deaths.
Reached 84% of the target population with messages on ITNs and documented a utilization
rate of 78% among respondents and 80% of their children in households that owned an ITN.
Tested 16,337 individuals for HIV, increasing by 67% from July 2010 through March 2011.
Improved already high administrative performance, so that by the latest quarter 100% of
facility staff were paid on time and 100% of HMIS reports were submitted on time.
Participated actively in 24 national working groups, task forces, and steering committees.
Made substantial contributions to the development of the Country Situational Analysis
Report for the Health Sector, and drafts of the NHSWP 2011–2021 and EPHS.
Despite these achievements, RBHS reported several areas in which performance and results
were not as expected. These included:
Delays in obtaining a USAID drug waiver and problems with the implementation of national
supply chain standard operating procedures (SOPs) may be contributing to stock-outs. The
team was informed that RBHS is actively working with USAID to identify ways to expedite
the drug procurement process, as well as with the MOHSW on the finalization of the
national supply chain standards.
Some community-level BCC activities have been slow to start due to holdups in production
of key information, education, and communication (IEC) materials and job aids caused by
lack of local production capacity/expertise and delays in the training of community health
volunteers.
Emergency obstetric and neonatal care (EmONC) services have not progressed as far as
planned because of inadequate infrastructure, equipment, staffing, and the postponement of
the release of the MOHSW‘s own roadmap for the reduction of maternal mortality. RBHS
continues to work with the MOHSW and partners on these issues.
Among the most challenging issues faced by RBHS is the absorptive capacity of counterparts
within the MOHSW and CHSWTs. RBHS takes its role in building capacity of MOHSW staff
seriously, but several counterparts lack capacity, willingness, or time; therefore, the transfer
of skills has been sub-optimal in many instances.
8 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 9
II. FINDINGS AND ISSUES
The following are summaries of what the assessment team deemed to be ―key‖ findings obtained
through the integrated data collection process.6 The findings as presented here do not reflect
the opinions of the assessment team but rather are, the team hopes, an accurate distillation and
packaging of the complete list of findings as recorded by the team.
TYPE: PROGRAMMATIC AND TECHNICAL
Taking into account the future direction of the project, there are two segments of critical
issues/findings in the programmatic/technical area namely:
1. Strengths/achievements/successes of the project that must be built upon to maximize impact
as the project moves toward the transition period.
2. Weaknesses/short-comings/hurdles that must be addressed during the period of transition
in order to guarantee gradual scale-up and sustainability. The issues reported by RBHS, sub-
partners, CHSWTs, and health facility staff—and then validated by the evaluation team
through field visits and review of documents—are described below.
Strengths:
RBHS:
1. Project introduced a data-driven culture in the national health care delivery system at all
levels with the goal of informing planning and decision-making.
2. The patient load in the facilities visited in three counties demonstrated an increase in
demand for services in catchment areas. This is an evidence of change in health-seeking
behaviors since the inception of the RBHS activities, and the services must be meeting the
needs of the care seekers. Services particularly mentioned were general care, ANC, delivery
services, and delivery short stay in the facilities.
3. Generally, delivery of the BPHS is on track. This can be attributed to commitment and
coordination at all levels (MOHSW, RBHS, USAID, sub-partners, CHSWT) to achieve the
intended results.
4. RBHS is effectively delivering BCC/health promotion activities using a two-pronged
approach: 1) Integrated activities addressing a wide range of health topics including six in the
BPHS: maternal and newborn health, child health, adolescent sexual and reproductive health,
communicable disease control, emergency care, and mental health; and 2) A series of
intense campaigns for limited duration on one or two specific health issues, e.g., malaria,
HIV/acquired immune deficiency syndrome (AIDS). These approaches complement and
reinforce each other in that they target audiences at the household, health facility,
community, county, and national level using media (radio programming) and interpersonal
communication activities using a selection of IEC materials (Liberia RBHS SBCC Strategy
Framework).
5. RBHS trained gCHVs and motivated them in various ways to sustain their enthusiasm in the
dissemination of basic health information in communities. GCHVs also encouraged care-
seeking behavior, especially among pregnant women, and sometimes escorted them to
health facilities for delivery. The network of community health volunteers (gCHVs, health
and hygiene promotion [HHP], and trained traditional midwives [TTMs]) represent a key
6 See Appendix D for the complete and detailed list of key findings.
10 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
factor in the success achieved so far. They are motivated through provision of materials,
supplies, training, and supportive supervision.
6. One of the strengths of the project is regular refresher training with the injection of
additional skills to both the facility staff and the community health volunteers.
7. Service providers at the facilities received regular supportive supervision. This includes:
feedback on previous visit, onsite training on various topics, technical and logistical/material
support including IEC/BCC materials provision, and psychosocial support. This level of
support for facility staff motivates them to enhance service delivery and improve outcomes.
8. RBHS support to central MOHSW includes: seconding a staff to the mental health
department, liaising closely with the Health Promotion Unit, and helping in the establishment
of a Community Health Unit directly at MOHSW.
9. RBHS is supporting the MOHSW in the development and production of standardized
protocols, guidelines, and policy documents that would harmonize service delivery and
enhance outcomes.
10. RBHS invites CHSWTs to join workshops with health care providers from RBHS-supported
facilities in order to transfer the knowledge of policies, procedures, and operational
guidelines, and thus increase the CHSWT‘s ability to assume a more active supervisory role.
Additional benefits include the development of relationships between the CHSWT and the
facility staff.
11. RBHS helps in making sure drugs and family planning commodities reach other health
facilities. This will avoid stock-outs and help these facilities meet standards and enhance
service delivery.
12. RBHS provides evidence-based service delivery through sub-partners. During field visits,
facility staff, sub-partners, and CHSWT spoke of service delivery in terms of numbers (e.g.,
increase in clinic attendance, outcome of facility-based deliveries).
13. Both CHSWTs and sub-partners are making deliberate efforts to effect good coordination
of activities through the coordination meetings, joint supervision, and on-time collection of
reports from clinics for CHSWT and transporting Global Fund drugs for tuberculosis (TB)
and AIDS control from CHSWT to clinics.
MOHSW:
1. MOHSW employs a participatory, inclusive approach in the development of key policies,
plans, and programs.
2. All health facilities visited were staffed in accordance with the MOHSW‘s BPHS. MOHSW,
with the support of RBHS, is working on the development and production of standardized
treatment protocols and guidelines to be provided to facilities for harmonization of activities
and outcomes.
3. MOHSW has positively adopted a data-driven culture introduced by RBHS that would be
used to inform good management and decision-making in service delivery.
4. MOHSW is fully committed to the delivery of quality and affordable health care services
with the technical and managerial support/mentoring by RBHS.
Weaknesses:
RBHS:
1. To the extent that dual reporting of project staff does exist to MOHSW through the
CHSWT and the sub-partners, it is time consuming for the officer in charge (OIC) and may
affect data quality and validity.
2. In some instances, the recruitment of community health volunteers is carried out without
the community involvement and engagement.
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 11
3. Project design was reported by RBHS and sub-partners to be too ambitious. The targets,
objectives, and indicators are reportedly too many. With a ladder progression approach in
the implementation, sub-partners and facility staff are overwhelmed, and less attention is
given to CHSWT capacity building.
TYPE: MANAGEMENT/ADMINISTRATION
Project management and administration is the basis upon which a project relies for the
organization and coordination of activities in keeping with certain rules and regulations, with the
purpose of achieving defined objectives. Management and administration lays the groundwork
for support of the implementation of the project‘s technical activities. Given the complex nature
and the scope of RBHS project, and taking into account the critical importance of management
and administration functions during the transition and beyond, the assessment team took a
critical look at JSI management of RBHS project. Like in the previous section, the team identified
the project‘s strengths, as well as weaknesses to be addressed, during the transition in order to
ensure continuity and sustainability. These issues were discussed in meetings with RBHS and
with sub-partners, CHSWT, and facility staff during field visits.
Strengths:
RBHS:
1. JSI has developed a strong partnership with key stakeholders including MOHSW,
USAID/Liberia, sub-partners, and other donors to support MOHSW in building its health
system and implementing its national health plan.
2. JSI has put in place a strong team of experienced professionals serving as Senior
Management Team of RBHS project. This team is directly supported by JSI Home Office and
Partners.
3. JSI plans to transition several key positions in the management team, e.g., COP, DCOP,
BCC advisor from expatriates to Liberian nationals during Year 3 of the project (through a
counterpart approach).
4. JSI has successfully introduced an innovative, cost-effective strategy for financing health
service delivery and health system strengthening in RBHS-supported areas through regular
communication and monitoring, to ensure compliance with USAID management rules and
regulations.
5. JSI has developed a strong M&E plan as a management tool that will enhance MOHSW
governance.
6. Incentive paid to facility service providers by RBHS was reported to be regular, timely, and
largely appreciated.
7. RBHS has successfully managed to establish a network of community health volunteers for
community outreach service. The assessment team ascertained that the network is visible in
the community through field visits.
8. Training, logistical support, and payment of performance-based bonuses provided by RBHS
to the facility staff and non-cash incentives to the community health volunteers contributed
to motivating staff/volunteers and keeping the project on track.
9. RBHS provides facilities with adequate equipment and supplies on a regular basis. No case of
a drug stock-out was reported during site visits.
MOHSW
1. The MOHSW affirms a central leadership role and commitment to transparency and
accountability, which has resulted, in part, in several donors having made contributions
directly to the Pool Fund.
12 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
2. The MOHSW‘s effective collaboration with partners enhanced its commitment and capacity
to strengthen the health system and improve service delivery.
3. The MOHSW has developed a NHSWP 2011–2021, as well as established appropriate
management structures and tools designed to oversee implementation of the health
strategy.
4. The MOHSW has built a strong financial and accountability system within the ministry that
will be an asset during the transition for transparency and sustainability.
5. The MOHSW decision to adopt the RBHS scheme within the ministry is an indication of its
commitment to decentralization.
Weaknesses:
RBHS:
1. The RBHS project was designed to implement vertical funding, and yet it implemented
horizontally in an integrated fashion. Each funding stream has its own set of indicators. This
is cumbersome for sub-partners. There is a need to focus only on the strategic specific
indicators as determined by the MOHSW.
2. As agreed to by RBHS, the lack of a baseline comprehensive assessment (programmatic,
managerial, and administrative) of all CHSWTs by RBHS prior to commencement of project
activities makes the identification of programmatic gains difficult to quantify and assess.
3. Health facilities whose PBCs do not meet their administrative indicators are also penalized.
This is unfair and depicts a weakness of the project, as it has the potential to de-motivate
health providers in affected facilities.
4. Field staff at visited facilities referred to delays in receiving drug supplies from MOHSW as a
demotivating factor.
5. The role, responsibility, and position of county coordinator in the county health structure of
the RBHS project are not clearly defined. Besides, not to provide office space for the
coordinator in one county is to weaken cooperation and collaboration between CHSWT
and sub-partners, much to the disadvantage of the project and its beneficiaries.
6. The level of effort required to cover all areas and health facilities by only an RBHS county
coordinator for supervision is overwhelming and might likely isolate him further from the
CHSWT.
7. There is no systematic information sharing by RBHS with other international organizations,
particularly the INGOs and UN agencies. This precludes RBHS from having access to
information from other organizations that could be used to strengthen the project.
8. RBHS has too many components for implementation, including managing sub-partners;
innovating finance approaches; strengthening service delivery; scaling up access to BPHS;
providing essential medicines and improving drug management; mobilizing and informing
communities; delivering services at community level; renovating health facilities; promoting
public-private partnership; and building institutional and human capacity and other vertical
interventions such as malaria, HIV, TB, and nutrition. Some components such as
infrastructure renovation, financing, and promoting public-private partnership are potentially
diverting focus from key technical aspects.
9. There is lack of communications capacity between health facilities and sub-partners. This
undermines timely information on notifiable diseases, reportable diseases, and referrals.
10. In some instances, CHSWT in one county reported that sub-partners initiated strategies and
activities without consulting CHSWT for direction and guidelines on specific issues.
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 13
MOHSW:
1. At the level of the central MOHSW, there is no budget for the Community Health Service
Division and the Health Promotion Division, two key divisions in enhancing implementation
of project activities at the community level. The implications are that service delivery may
suffer and that there is no consistency between and among the MOHSW, CHSWT, and sub-
partners. For example, according to the revised MOHSW plan, TTMs are no longer
supposed to do deliveries, but rather are being directed to assess pregnant women for
danger signs and escort them to facilities.
2. At present, the MOHSW staffing pattern favors central administration over the CHSWT
level (e.g., most health facilities visited are understaffed). Health care providers are not
uniformly identified on the MOHSW payroll.
3. The success and sustainability of the project depends heavily on community involvement and
behavior change amongst the care-seekers, yet the health promotion division at the
MOHSW central is weakly represented in all the CHSWT structure and function.
4. As agreed to by RBHS and MHSW in discussions with the team, dual reporting, if it exists,
to CHSWT and to sub-partners by project facility staff is time consuming for OICs.
5. Delay in disbursement of the quarterly subsidy to CHSWTs makes it difficult for them to
motivate the network of community volunteers. This also impedes regular supervision of
activities and reduces the probability of reaching targets.
6. The reported lack of budget lines for the Community Health Services and the Health
Promotion divisions at MOHSW central filters to the CHSWT level, hampering adequate
delivery of community health services (e.g., BCC/health promotion at the household,
individual, and community levels).
7. There are difficulties with motivation and retention of staff in all facilities (RBHS-run and
government-run). One contributing factor to low motivation is the low level or lack of
income. Although incentives are not the only motivating tool, the incentives currently paid
to health workers are based on civil service ceilings, which are low. Such low incentives do
not attract health workers to work in rural areas. Alternatively, many choose to work in
private facilities in Monrovia where there is potential for more income.
8. The lack of a clear MOU or another administrative instrument between the MOHSW, the
CHSWT, and sub-partners negatively affects the working relationship between CHSWT and
sub-partners, which in turn affects CHSWT performance.
9. Currently capacities vary widely from county to county. In certain cases, such as the county
health officer and hospital medical director, the requirements of simultaneously being
clinicians, managers, and administrators are cumbersome and should be separated.
10. Future CHSWT composition might include the county health officer, a hospital medical
director, a community health department director, a county health service administrator, a
county surveillance officer, a county health education officer, and a county M&E coordinator.
CROSS-CUTTING:
The cross-cutting issues identified in the Scope of Work (SOW) have been discussed in the
technical/programmatic and management/administration sections. The assessment team deemed
it necessary to focus only on RBHS strengths in this section.
RBHS Strengths:
1. RBHS is well integrated with the MOHSW, particularly at the county, facility, and
community level where activities are being implemented. Two good examples of how RBHS
has made a significant difference in how the MOHSW operates are the introduction of a
14 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
data-driven culture at all levels in the health system and the strengthening of the HMIS. The
establishment of a culture of use of information for planning and decision-making is
improving service delivery quantitatively as reported by facility staff during site visits. If
maintained, this culture will strengthen service delivery in a sustainable manner beyond the
life of the project.
2. RBHS‘s planned strategy to transition senior management functions from expatriate staff to
Liberian nationals during Year 3 of the project is a strong support to the MOHSW assuming
leadership and a rational move toward sustainability. Other elements of progress toward
sustainability include institutionalization of PBF and standardization of health policies,
procedures, and capabilities at all levels.
3. One good example of work done by RBHS to strengthen national institutions, professional
associations, and NGOs is the Pre-service Education Initiative (PSE), which was designed to
improve the secondary/undergraduate curriculum of mid-level health care providers, the
educational environment in both the classroom and clinical sites, and the overall
management of selected teaching institutions. Developed in collaboration with the MOHSW,
professional, and regulatory bodies, and other key stakeholders, PSE is directed primarily at
improving the level of education for trainee registered nurses (RNs). Physician‘s assistants
(PAs), CMs, EHTs at two schools (The Tubman National Institute of Medical Arts [TNIMA]
and the Esther Bacon School of Nursing and Midwifery [EBSNM]). PSE has already led both
educational and clinical standards for the training institutions. According to RBHS, several of
the strategies, standards, and tools developed by PSE have already been adopted by six
other training institutions for mid-level health workers, as well as the associated professional
boards and associations.
4. To ensure coordination and synergy with the GOL, JSI has developed a partnership with key
stakeholders including the MOHSW, USAID/Liberia, sub-partners, other donors (e.g., Pool
Fund) to support the MOHSW in building its health system, developing and implementing its
NHSWP 2011–2021, and thus contributing to USAID/Liberia intermediate results 1 & 2 and
assisting the GOL in meeting its health millennium development goals. The
operationalization of this partnership is still evolving in areas such as data sharing.
5. RBHS chose to address youth- and gender-related issues within several components of the
project, including reproductive health, HIV/AIDS, maternal and child health, and in-facility
deliveries. Addressing youth and gender issues within established key components affecting
adolescent girls and boys, as well as women‘s lives, is more practical, cost-effective, and
likely to have an impact since these components are already receiving much attention.
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 15
III. DISCUSSION:
The USAID-funded RBHS project appears to be a good example of cooperation between the
GOL and the U.S. Government. RBHS demonstrates the desire of both governments to work
together in implementing activities leading toward strengthening the Liberian health system in
the post-war period and improving the lives of people severely affected by the 14 years of social
unrest. The health and lives of men, women, children, and youth are significantly being positively
affected by the services of the project, as reported by the staff of the project‘s health facilities
that were visited in Cape Mount, Bong, and Nimba Counties. RBHS reports that the project has
made notable achievement in service delivery both at the health facility and community levels. A
deputy MOHSW minister lauded the project as being ―ahead of the curve‖ in its endeavour to
strengthen the Liberian health system and to improve service delivery all over the country. The
fact that RBHS is a recognized partner with the government and other development partners
bodes well for the project‘s ability to continue to show leadership at the central level and
below. The project at this point appears to be on track.
It is important to acknowledge the Liberian context within which the project is being
implemented. The health sector was making significant gains in improving the lives of its citizenry
before the 1989 civil war. The socio-economic decline that followed eroded all the gains made
in previous years. The health sector in Liberia continues to evolve in the post-war period.
Health services during the war years were funded by the UN system and the international
community. Presently, the MOHSW is taking a strong leadership in decision-making and
delivering the health sector activities. Many critical policies, plans, criteria, organizational units,
management, structures, and implementation of plans are being developed. Some are near
completion and others are adopted as the NHSWP 2011–2021. The RBHS project is being
implemented in an environment where expectations are high at all fronts, the health system is
being rehabilitated and/or reconstructed, and plans and policies are being formulated. This
situation creates both an opportunity to contribute to the process for the development of a
sustainable health system and a challenge to deal with many factors, realities, and policy
limitations in navigating through the process.
In Liberia the modus operandi at this moment in time calls for flexibility, patience, and
understanding as the enabling environment for health service delivery is being crafted. The RBHS
has already had one revision in response to the evolving situation, and is about to experience
another to direct its final two years of effort in ways that are supportive of the government‘s
commitment to a path of decentralization self-control. Further complicating the equation is the
fact that many of the programmatic and technical areas in which RBHS has, can, and is expected
to make significant contributions are still being defined within the context of the MOHSW‘s new
strategy and governance plans.
It is clear to the assessment team that RBHS and all stakeholders need to adjust their thinking to
assume more of a ―systems‖ approach to health care governance and the realization of desired
health outcomes throughout the country.
Projects need to be designed with targets that accurately reflect systemic considerations in all
areas including but not limited to: planning, coordination, program integration, outcomes,
management, M&E, and the consistent institutionalization of policies, procedures, and
capabilities, not only at the central level, but also at the county, district and facility levels.
The network of community health volunteers is one of the major successes of the RBHS
project. For a project whose achievements depend on the improvement of health-seeking
behaviors and the adoption of healthier behaviors by the community, the role of this category of
16 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
community health workers is paramount. They are needed to effect changes at the individual,
household, and community levels. However, the project needs to take a step further in ensuring
active community involvement and commitment, which will pave the way to sustainability of the
project‘s activities. Therefore, the communities should be consistently involved in the
recruitment and motivation of these volunteers.
Moreover, the issue of motivation of these volunteers needed a detailed discussion in a national
health forum. An analytical review of the gCHVs scope of work will help MOHSW and RBHS
decide how to motivate them. For example, facility staff in Grand Cape Mount County give cash
incentive to TTMs in addition to the non-incentive from the project. Each woman escorted by a
TTM to deliver at the facility is asked to pay $LD350. This amount is then given to the TTM by
the facility staff. This motivates TTMs to escort pregnant women to the facility for delivery. This
community decision to motivate volunteers should be also discussed in order to find innovative
ways for motivating volunteers.
Finally, RBHS has introduced a data-driven culture into the health system. Staff also show off
their newly earned technical skills. This is a laudable achievement. However, if this newly
acquired skill is not nurtured and sustained it may become counterproductive. In the next phase
of the project, emphasis should be placed on quality of service, quality of data generated, quality
of support given, and the number of meetings and trainings conducted.
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 17
IV. CONCLUSIONS
The evaluation team documented that the RBHS project has made significant progress in
meeting its objectives, with the weakest areas being associated with capacity building,
infrastructure development, and public-private partnership (PPP). The evaluation team also
documented that:
1. RBHS receives strong technical support from USAID and the Mission, and has been very
responsive in turn.
2. RBHS sub-partners are committed, engaged and supported by RBHS.
3. CHSWTs are committed and engaged as well, but are still frustrated by the inadequate
technical capacity building and logistical support they receive.
4. Coordination and collaboration between RBHS sub-partners and CSWHTs are not working
properly.
5. Insufficient attention is given to the quality of services provided.
6. Ultimate output of the project is not expressed in terms of ―health outcomes,‖ such as
changes in health profiles of communities or families, but rather in terms of numbers of a
unit of measurement defining an action—not an impact.
The assessment team recognizes a need for the development of detailed implementation plans
to guide activities at all levels, both during the transition and beyond. These plans must be
integrated within and between all levels of the health care delivery system and must be
supported by an interrelated set of policies, procedures, guidelines, rules and regulations, and
other systemic and institutional arrangements necessary to create and maintain a supportive,
enabling environment.
In the light of the above findings, issues, discussion, and conclusions, it appears that RBHS has a
significant role to play in a number of areas critical to the ultimate creation of an effective and
sustainable health care delivery system, both owned and operated by the MOHSW, in Liberia.
Regarding the MOHSW‘s assuming responsibility for managing the PBC program, the assessment
team is deeply concerned that there may be deterioration of the quality of services if the plan is
not implemented at a pace that is responsive to the capacity of both central MOHSW staff and
CHSWTs to manage. The transition should be carefully managed and timed to prevent
deterioration of service delivery.
Another major theme of the findings is related to the need for the MOHSW to develop systems
that will help recruit and retain health workers, particularly those assigned to rural areas. This is
especially important for the MOHSW‘s commitment to decentralization. In order to
institutionalize a rational human resource infrastructure, many issues need to be revisited—
including salary levels and incentives for service.
The structure of the CHSWTs should be revisited to ensure that necessary skills and capabilities
will be in place and able to function effectively within a decentralized system.
Some possible county health system functions may include: planning, data collection, analysis
and consolidation, M&E, surveillance, stakeholder coordination, health education, service
delivery, and financial management.
18 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
Building the capacity of the health care delivery system in Liberia will also require strengthening
the academic training, including curricula and in-service training programs, and programs in
health care-related fields, in order to produce more qualified graduates in areas such as nursing,
midwifery, public health, physician assistant work, etc.
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 19
V. RECOMMENDATIONS:
The following recommendations reflect the assessment team‘s belief that the approach used by
RBHS and other implementing partners in Liberia should reflect a shared commitment to
systemic reform and systemic capacity building. Therefore, the team offers these
recommendations in the belief that, (1) activities are all interrelated, and that the cumulative
impact on decentralization and the transition to government ―ownership‖ is what needs to be
orchestrated, and (2) the ultimate measure of success will be in terms of both the sustainable
provision of quality health care and the measurable health outcomes.
Some of the recommendations, particularly those to be undertaken at the central MOHSW
level, are identified as a recognition that progress may already be being made in some of these
areas by other parties, including the development of policies and procedures to guide human
resource management in the ministry, financial management, etc. In such cases, the team
believes that RBHS can and should make contributions, as they have in so many ways to date. By
being active and visible on a daily basis, RBHS can work to ensure that the county health care
delivery system is not only represented but also, and perhaps most important, is functionally
integrated within the Liberian health care system. RBHS has an important role as a ―bridge‖
between the county health care delivery system and the central ministry, facilitating the
institutionalization of the relative roles.
Recommendations are made for the MOHSW, USAID, RBHS, and grouped into three
categories: programmatic/technical, management/administrative, and cross-cutting.
RECOMMENDATIONS FOR THE MOHSW
Programmatic/Technical
1. Consider the need for additional public health indicators that measure specific health
outcomes for use at the central and county levels.
2. Enhance the human, financial, and logistical capacity of the Health Promotion Division at the
central and county levels to allow it to take leadership in rolling out BCC activities during
the transition and beyond. The MOHSW should consider expanding the translation of
current and future BCC/health promotion programs in local Liberian languages for a
broader reach and efficiency.
3. Review the previous RBHS experience using cell-phone free airtime and messaging targeting
women and youth, assess what went wrong in the partnership with the cell phone company,
negotiate a new contract adequate for both parties, and revive this activity, which is likely to
reach a large portion of the target audiences nationwide where there is network.
4. Develop a pilot community wellness program to include mental health modules
(surveillance, education, and services).
Management/Administrative
1. Take leadership at all levels in the management and coordination of the RBHS project
activities and effect actual coordination among stakeholders and donors.
2. Strengthen public heath leadership at the central and county levels to ensure continuity in
and integration of policies, procedures, capabilities, and operations from central down
through facility levels, with particular attention being given to mid-level managers and
CHSWTs.
3. Design a model CHSWT structure and areas of functional responsibility.
20 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
4. Develop a county-wide facility and equipment infrastructure development, facility
management and maintenance plan, and equipment maintenance plan, as well as related local
servicing capability.
5. Revise human resource training, recruitment, and retention policies and programs to ensure
equitability, consistency, and competency at all levels of the health care delivery system in
Liberia. Such things as salary scales, incentives, and academic training programs must be
considered and, if appropriate, revised.
6. The structure of the CHSWTs should be revisited to ensure that necessary skills and
capabilities will be in place and able to function effectively within a decentralized system.
Combined functions of county health officers and hospital medical directors as managers,
administrators, and clinicians should be separated out and assigned to others as appropriate.
RECOMMENDATIONS FOR USAID
Programmatic/Technical
1. Consider reducing and focusing project indicators in order to reduce the administrative
burden, and focus on specific health outcomes and quality of service.
2. Consider narrowing RBHS scope of operation by removing the infrastructure, health
financing, and PPP development elements from the Project Cooperative Agreement and
assigning them to other entities that specialize in each of those areas. This will allow RBHS
to focus on targeted outcomes and quality of service. The transferred activities should,
however, be closely coordinated with the RBHS project to facilitate planning and support
effective service delivery and health outcomes.
Management/Administrative
1. Negotiate with the MOHSW a reasonable (one or two year) transition period, continue
capacity building support, and see what political change will bring.
2. Emphasize collaboration between RBHS and other USAID health projects in order to realize
synergies and cumulative impacts achievable through leveraging.
RECOMMENDATIONS FOR RBHS
Programmatic/Technical
1. Conduct jointly with the MOHSW a comprehensive assessment of the CHSWT and the
whole county health sector‘s (CMO), county health team [CHT], administrators, network of
volunteers, other local stakeholders) capacity and potential to determine the capacity-
building needs to be addressed in order to support the MOHSW policies and objectives, as
well as strengthen community health strategies and services.
2. Implement a mentoring program at MOHSW central through a counterpart approach to
strengthen the technical, managerial, and information management capacity of MOHSW
central in senior positions including: deputy CMO/assistant minister for curative services,
deputy CMO/assistant minister for preventive services and managers/directors of strategic
programs and divisions including the Health Promotion Division, the Community Health
Services Division, the Family Health Division, the National AIDS Control Program, National
TB/Leprosy Control Program, the Environmental Health Division, and other key
management units. Technical capacity building should specifically include information
technology at all levels.
3. Facilitate the MOHSW‘s strengthening of the HMIS through coordination between central,
mid and low levels. Mechanisms for the generation of accurate, timely, and qualitatively
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 21
relevant data need to be strengthened and institutionalized through strong supervision,
M&E, and HMISs.
4. Work collaboratively with the MOHSW to establish a strong training unit at the central
level to oversee and coordinate all training/capacity-building needs at all levels
5. Conduct an assessment of the highly touted Bomi experience with PBC in order to identify
lessons learned and applicability to other counties in Liberia.
6. Support and increase current MOHSW Health Promotion Division IEC/training/outreach
capacity (using the counterpart approach) in designing and implementing nationwide social
and behavior change communication (SBCC) and integrated health promotion programs in
keeping with the National Health Communication Strategy. These programs should build on
past BCC programs implemented in Liberia and particularly draw upon the current RBHS
SBCC effort, which has, according to the MOHSW, the CHTs and health facility staff,
contributed a fair share of appreciable results in terms of increase in demand of services and
improvement in health-seeking behaviors. The programs should use all available media
(formal and informal), technology, IEC materials, and outreach capabilities to reach both the
vulnerable and the general population at the individual, household, health facility, community,
county, and national levels. RBHS should also support the capacity of the MOHSW Health
Promotion Division to produce relevant and cost-effective IEC materials locally.
7. Develop and implement a sound, long-term BCC M&E plan that would go beyond the use of
the dip-stick approach, which only measures reach/exposure at one point.
8. Intensify, reinforce, and expand the current RBHS-run vertical campaigns and integrated
health promotion activities by engaging women, men, and youth at homes, health facilities,
schools, churches, mosques, women associations, market places/events, youth clubs, sport
events, workplaces using peer education, radio spots, audio drama series, listening clubs,
community dialogues, and other social networks on key issues such as reproductive
health/family planning, HIV/AIDS, and water, sanitation, and hygiene (WASH).
9. Capitalize on ongoing advocacy with the leadership at national level, and develop a model of
community mobilization and empowerment through the evidence-based Champion
Community approach on issues like WASH and malaria.
10. RBHS revised work plan should have a perspective of the interrelatedness of the complete
health care delivery system, and, as such, should be developed according to the following
guidelines:
– Consistency with the NHSWP 2011–2021 and two-year County Operational Plans.
– Stakeholder involvement of all significant parties in each administrative level (central,
county, district, facility) to include the administration, service provider, end users,
private sector, CHSWT, public health, and curative leadership, etc.
– Management/Administrative
11. Communicate implementation plans with the curative service at the MOHSW to augment
cooperation and service delivery.
12. Facilitate MOHSW development of an administrative instrument (an MOU) between sub-
partners and CHSWTs with clear roles and responsibilities, strategies, targets, indicators,
and a monitoring plan.
13. Support the MOHSW to develop standardized management instruments, including
supervision checklist and tools, mechanism for accurate data collection and management,
and a national referral system.
14. Support the MOHSW‘s External Aid Coordination Office by sharing information on a
regular basis with other organizations, particularly NGOs and UN agencies within an
22 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
MOHSW framework, with the goal of ensuring consistency of programs with adopted plans
at all levels.
15. Contribute to the review and revision of a structured salary scale for all health providers in
the public sector. Variables to be considered include annual salary adjustments based on
performance reviews and incentive program for staff serving in rural areas. Similarly RBHS
should facilitate a thorough review by the MOHSW of strategies that will promote and
sustain the motivation of the network of community health volunteers and ensure their
applicability.
16. The role of RBHS county coordinator needs a clear definition with respect to the position
in the CHSWT, organogram, and scope of work. This will address the problem of
collaboration that is much needed between these two entities to support the achievement
of the project‘s objectives. The pending hire of county capacity coordinators represents a
significant response to the need for coordination and collaboration.
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 23
APPENDIX A. SCOPE OF WORK
Global Health Technical Assistance Project
GH Tech
Contract No. GHS-I-00-05-00005-00
USAID/Liberia
Rebuilding Basic Health Services (RBHS) Year 2 Assessment
Scope of Work
(Revised: 06-21-11)
I. TITLE
Activity: USAID/Liberia RBHS Project Assessment
Contract: Global Health Technical Assistance Project (GH Tech), Task Order No. 01
II. PERFORMANCE PERIOD
The period of performance will run approximately on or about July 11, 2011 through
August 31, including approximately 3–4 weeks of in-country work (beginning around
July 18, 2011).
III. FUNDING SOURCE
The funding source will be through USAID/Liberia field support funds (up to $107,088). The
balance will be funded by AFR/SD.
IV. BACKGROUND
The Rebuilding Basic Health Services (RBHS) project is a five-year Cooperative Agreement
(2008–2013) with JSI Research and Training, in collaboration with JHPIEGO, the Johns Hopkins
University Center for Communication Programs (JHUCCP), and Management Sciences for
Health (MSH). Following a modification of the project in 2010, the project has three main
intermediate results: 1) increased access to basic health services through improved provision of
quality health services and adoption of positive health behaviors; 2) increase the quality of health
services through improving infrastructure, and health workforce and systems performance by
enhancing capacity to plan, manage, and monitor a decentralized health system; 3) youth
informed and networked on reproductive health.
V. PURPOSE
The purpose of this assessment is to review the performance and the progress of the five-year
Rebuilding Basic Health Services (RBHS) project, which is now at its mid-point, and assess the
appropriateness of the project design. The assessment shall identify factors enabling or
impending effective implementation of different components of the project. The assessment will
also advise USAID/Liberia on any needed redirection of strategies or priorities, which might
modify currently utilized approaches and/or suggest further expansion of the project. More
specifically, the evaluation team is expected to assess the progress made in achieving the three
intermediate results. The review should also include a cursory look at the progress made in
relation to operationalizing the six key principles in the program description.
24 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
Additionally, the assessment team shall identify lessons learned and provide suggestions for the
future direction of Liberia‘s health initiatives in order to assure a comprehensive and consistent
maternal and child health strategy, and determine new areas for technical support. The team will
allocate approximately 85% of its effort to assessing RBHS project accomplishments, and JSI‘s
management approach, and the other 15% will be allocated to making recommendations for the
future direction of health initiatives in Liberia.
The team members will, through interviews, data collection, and review of the resources,
provide answers to the following questions:
VI. ISSUES TO INVESTIGATE
Programmatic/Technical
Is the RBHS project on the right track to achieve the results targeted? What major changes,
if any, need to be made? Are there any significant gaps?
– Are the project goals and objectives realistic or overly ambitious? Are there too many
components to be implemented under one broad umbrella?
What are the strengths and innovative activities being undertaken that should be
continued/emphasized and may be a best practice for other USAID development activities?
– What are the most notable successes (exceeding expectations)?
What were the major shortcomings or failures? What were the challenges or changes in
circumstances that explain these successes or failures?
How effective has the RBHS project been in improving capacity to meet the growing
demand for basic health services and in promoting healthy behavior change as these relate
to the results sought by priority USG and GOL programs: 1) HIV/AIDS; 2) Maternal and
Newborn Health; 3) Child Health; 4) Malaria; 5) TB; and 6) Family Planning and
Reproductive Health (FP/RH)?
– To what extent was the project‘s effectiveness helped or hindered by its integrated
funding (six program elements) and design? What are the special challenges it faces as an
integrated program? Were there any significant missed opportunities? What were they?
How well has RBHS been able to utilize core competencies of its partners (JSI, MSH,
JHPIEGO, JHUCCP)?
How well has RBHS been able to manage its sub-grantees/contractors to maximize health
impact through the delivery of the Basic Package of Health Services (BPHS) (e.g., providing
technical and operational guidance to systematize/harmonize activities and scale-up best
practices and lessons learned)?
– Are all components of the BPHS delivered through the sub-grantees being adequately
met? How can service delivery be further improved?
Has the program learned any lessons about a ―ladder of progression‖ for phasing in
elements of the BPHS? Is there a harmonized approach that could be developed from the
different experiences to date?
What have been the implications of standardization of the BPHS? Has this expanded the
capacity of NGOs that traditionally had a more limited focus? Has it stretched NGOs
positively—or too rapidly?
Is the training approach used by RBHS reasonable given the Liberian context? Please
describe some of the challenges and how RBHS has responded?
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 25
What has been learned about health-seeking behavior and creating demand in Liberia? How
effective has RBHS been in learning the Liberian context and in applying it to IEC/BCC
message content and delivery?
How successful has the program been at building a national HMIS capacity, both at the
central level and linked to the county level?
Comment on the degree to which RBHS has integrated key gender and youth concepts into
its overall programming. What are the strengths and weaknesses?
Cross-Cutting
How well does the project respond to the government‘s desired direction for Liberia? Is the
structure of the project well integrated with the MOHSW program to assist the GOL in
meeting its health MDGs? Cite any examples of where the program made significant
differences in how the MOHSW operates, results obtained, and its reform and direction.
What elements of the program are making progress toward sustainability? What are not,
and what else could be done?
Describe the work done to strengthen national institutions, professional associations, and
NGOs. What are the major results, challenges, and recommendations?
How does the program complement the work of other donors, NGOs, and MOHSW
health programs? Any missed opportunities and what recommendations?
What mechanisms are in place to ensure coordination and synergy with GOL, other donors
(specifically Pool Fund, GAVI, and GFATM), and other United States Government supported
activities? How effective are these? What recommendations?
Management
How well is the overall administrative and implementation structure working to manage and
carry out project objectives?
– How well is the RBHS team, including management structure and staff positions,
interacting productively with the AOTR and AO, USAID health team? Discuss relative
strengths and weaknesses?
How is the current program being managed (both technically and financially)? Discuss the
degree to which this management approach adequately documents decisions made,
accomplishments and changes. Discuss any challenges to the management‘s approach that
affect outcomes.
How well does communication flow between the prime and sub-grantees? What are the
successes and challenges? Discuss any recommendations for improvement.
How effectively is RBHS managing the planned transition in project leadership to a Liberian
COP?
How effectively has USAID been able to manage the RBHS project and provide needed
management and technical direction? What have been barriers or shortcomings?
Future Direction
What are overall impressions of the RBHS project and recommendations for current and
future programming?
What are the three key lessons learned that the Mission should focus on when developing
its upcoming follow-on projects and implementing the new CDCS and GHI strategy?
26 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
How can the project achieve a successful rollout to other areas not targeted by the current
RBHS project? In other words, how can RBHS project‘s successes best be institutionalized
nationwide?
What recommendations would you make regarding future plan or approach for
sustainability of service delivery when external funding, which is now very significant,
inevitably declines?
How have the funding earmarks (POP, ID) affected the program? How well has the program
been able to meet the requirements of the earmarks and report on them? Has there been,
or does there need to be, a course correction to match the program with the funding
categories?
How have the program activities been perceived by beneficiaries and stakeholders (end-
users, NGOs, MOH, UN agencies and other donors), the Mission, and the embassy? What
have been the drawbacks of the US visibility and/or invisibility?
VII. METHODOLOGY AND PROCEDURES
The evaluators should consider a range of possible methods and approaches for collecting and
analyzing the information required to assess the evaluation objectives. The methodology will
include, but not be limited to: team planning meeting (TPM), document review, key informant
interviews (including USAID/Liberia staff and GOL and other donors/international agencies), site
visits to several of the 108 health facilities assisted by the project, 2 training schools, and direct
observation.
Existing Data Sources
The team will review briefing materials that will be provided by USAID/Liberia including but not
limited to the following:
Technical Assessments of RBHS, BASICS, and other groups (2004–2010)
Draft Mission Strategy document 2006–2009
RFP for the RBHS
Cooperative agreement RBHS (2008) and Amendments
RBHS first and second year work plans
RBHS first and second year annual reports
PMP of the Mission
Mission Semi-Annual Performance Reports
Government of Liberia key documents (PRS, National Health Policy and Plan, Roadmap to
Maternal Health, Situational Analysis, Nutrition Strategy and Plan, Sexual and Reproductive
Health Strategy, etc.)
Liberia DHS 2007, MIS 2009, and Comprehensive Food Security and Nutrition Survey 2010.
2011 LQAS survey report
Team Planning Meeting (TPM)
The assessment team will start their work with a two-day planning meeting prior to the onset of
key stakeholder meetings and field work. The purpose of the TPM will be to clarify team roles
and responsibilities; to develop the work plan and methodology; and to create a timeline and
action plan for completing the deliverables. In the meeting, the team will specifically:
Share background, experience, and expectations of each of the team members for the
assignment;
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 27
Formulate a common understanding of the assignment, clarifying team members‘ roles and
responsibilities;
Agree on the objectives and desired outcomes of the assignment;
Establish a team atmosphere, share individual working styles, and agree on procedures for
resolving differences of opinion;
Revisit and finalize the assessment timeline and strategy for achieving deliverables;
Develop and finalize data collection methods, survey questionnaire, and guidelines;
Develop preliminary outline of the team‘s report and assign drafting responsibilities for the
final report.
During the TPM, an in-briefing with USAID/Liberia will be held to discuss expectations of the
assessment.
Data Collection:
The information collected will be mainly qualitative guided by a key set of questions. Information
will be collected through personal and/or telephone interviews (rarely) with key contacts,
through document review, and through field visits. The full list of stakeholders and contacts will
be provided. Additional individuals may be identified by the evaluation team at any point during
the final evaluation. Key informant interviews will include but not limited to:
RBHS program managers and sector specialists in the field
USAID/Washington and USAID/Liberia technical team members
GOL/MOHSW counterparts
Donors (World Bank, UNDP, UNICEF, DFID, GFATM, WHO, EU)
Project directors for other USAID projects such as MCHIP, HS20/20 etc.
Staff from selected partner NGOs of RBHS
County level local leaders, administrators, stakeholders
RBHS beneficiaries
Field visits:
The team will coordinate with USAID/Liberia to prepare for and conduct site visits while in-
country, and to interview key informants at these sites. Site visits will be conducted in Bong
County (three days) to see one sub-grantee: Africare; in Nimba County (five days) to see two
subgrantees: EQUIP and International Rescue Committee (IRC); and in Grand Cape Mount (two
days) to see MTI.
Briefing/final debriefing meetings with USAID/Liberia Staff:
The evaluation team will meet with the USAID/Liberia health team to review the scope of the
final evaluation, the proposed schedule, and the overall assignment. The initial briefing will also
include reaching agreement on a set of key questions and will take place over one day (or could
be incorporated into the TPM).
At least two days prior to ending the in-country evaluation, the team will hold a debriefing with
USAID to present the major findings and recommendations of the evaluation. These
recommendations will focus on the accomplishments, weaknesses, and lessons learned in the
program, including recommendations for improvements and increased effectiveness and
efficiency of the RBHS program.
28 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
VIII. SKILLS AND LEVEL OF EFFORT
Team Composition
A Team Leader, with expertise in health systems development, public health management,
and/or institution building, who will be an international consultant with extensive USAID
program implementation and evaluation experience, must possess proven skills in assessment
and analysis of post-conflict/transitioning development programs. She/he must have a proven
track record supervising teams in the field and producing high quality and concise reports, as
well as extensive experience working in Africa and similar fragile/post-conflict settings. The team
leader will:
Finalize and negotiate with USAID/Liberia the evaluation work plan;
Establish evaluation team roles, responsibilities, and tasks;
Develop data collection instruments/questionnaire
Facilitate all necessary meetings in the U.S. and in Liberia;
Ensure that the logistics arrangements in the field are complete;
Coordinate schedules to ensure timely production of deliverables;
Coordinate the process of assembling individual input/findings for the evaluation report and
finalizing the evaluation report;
Lead the oral and written preparation and presentation of key evaluation findings and
recommendations to USAID/Liberia.
Two Local Consultants with broad knowledge of Liberian health issues will assist in key
informant interviews, data collection, qualitative instrument preparation, and analysis of
collected data. Combined qualifications should include: expertise in maternal, child, and newborn
health; family planning and reproductive health; infectious disease prevention and control.
Additional expertise in WASH and health systems strengthening (especially human resource
capacity development) is preferred.
An international expert in BCC/IEC will assist the Team Leaders in the duties above—in
addition to expert analysis related to BCC/IEC component of RBHS. IEC/BCC expert should
have a proven track record of successful project assessment and evaluation—preference given
to experience evaluating USAID projects.
An internal USAID program officer will join the team to support logistics and coordination, as
well as provide technical expertise. With an MPH, the program officer will provide expertise in
health systems strengthening. This fifth team member is funded by USAID and will not require
financial support from GH TECH.
Level of Effort
An illustrative table of Level of Effort (LOE)* follows:
Activity Team
Leader
Local
Consultant 1+2
BCC
Advisor
Preparation and pre-field work (remote work) 5 days 4 days 4 days
Travel to Liberia 2 days 0 days 2 days
Team Planning Meeting (TPM) (in-country work) 1.5 days 1.5 days 1.5 days
* A six-day work week is authorized when consultants are working in country.
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 29
Activity Team
Leader
Local
Consultant 1+2
BCC
Advisor
Briefing Meeting with USAID/Liberia (in-country
work) 0.5 day 0.5 day 0.5 day
Interviews with key informants (in-country work)
and Site Visits (in-country work) 12 days 12 days 12 days
Document Review (in-country work) 1 days 1 days 1 days
Drafting of Evaluation Report and any necessary
interview follow-up (in-country work) 3 days 3 days 3 days
Debriefing Meeting with USAID/Liberia (in-country
work) 1 day 1 day 1 day
Travel- Return Home 2 days 0 days 2 days
Finalizing Report (remote work) 5 days 3 days 3 days
Total LOE (estimated) 33 days 26 days 30 days
IX. LOGISTICS
The Mission will assist in arranging local meetings and provide some transportation assistance
for appointments in Monrovia.
GH Tech will provide transportation to and from Liberia and arrange for local lodging and
transportation (as needed).
X. DELIVERABLES AND PRODUCTS
Deliverables
1. A written work plan prepared during the TPM and submitted to the Mission for review and
approval before fieldwork and key informant interviews begin.
2. A draft report outline prepared during the TPM.
3. A Mission debrief meeting that will be held before the team‘s departure and prior to the
submission of the draft report. The team will prepare a PowerPoint presentation for this
event.
4. Prior to departing Liberia, a draft report addressing key performance findings, conclusions,
recommendations and lessons learned will be submitted. Feedback from the final debriefing
will be incorporated into this draft report. The mission will have 10 days following the
submission of the draft report to respond and provide written comments and feedback to
GH Tech.
5. The final report will be due five days after receipt of the comments from USAID/Liberia. It
will be the property of USAID. Dissemination of relevant findings will occur through official
channels at local (Mission, USG and stakeholders) as well as Washington level. Some of the
findings may be used for country operational planning. The report shall not exceed 30 pages,
excluding the annexes.
– The revised final unedited report will be provided to the mission five days after the
comments are received.
30 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
– Once the mission signs off on the final unedited report, GH Tech will have the
documents edited and formatted and will provide the final report to USAID/Namibia for
distribution (five hard copies and CD ROM). It will take approximately 30 days for GH
Tech to edit/format and print the final document. This will be a public document and
will be posted on the USAID/DEC and the GH Tech websites.
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 31
USAID/Liberia will provide a Mission car and driver for use by GH Tech Consultants only
when other USG staff members accompany them. When no United States Government staff
members accompany consultants, they will use taxis.
Prior to In-country Work:
USAID/Liberia will undertake the following:
Consultant Conflict of Interest. To avoid conflicts of interest (COI) or the appearance of a
COI, review previous employers listed on the CV‘s for proposed consultants and provide
additional information regarding any potential COI.
Background Documents: Identify and prioritize background materials for consultants and
provide them to GH Tech as early as possible prior to teamwork.
Key Informant and Site Visit Preparations: Provide a list of key informants, list of health
facilities and suppliers, and suggested length of field visits for use in planning for in-country
travel and accurate estimation of country travel line items costs (i.e. number of in-country
travel days required to reach each destination, and number of days allocated for interviews
at each site).
Lodging and Travel: Provide information as early as possible on suggested lodging and
identify a person in the Mission to assist with logistics.
During In-country Work:
USAID/Liberia will undertake the following while the team is in country:
Mission Point of Contact: Ensure constant availability of the Mission Point of Contact
person(s) to provide technical leadership and direction for the consultant team‘s work.
Meeting Space. Provide guidance on the team‘s selection of a meeting space for interviews
and workshops (i.e., USAID space if available, or other known office/hotel meeting space) if
appropriate.
Meeting Arrangements and Field Visits. While consultants typically will arrange meetings for
contacts outside the Mission, support the consultants in coordinating meetings with
stakeholders and organizing site visits.
Formal and Official Meetings. Arrange key appointments with national and local government
officials and accompany the team on these introductory interviews (especially important in
high-level meetings).
Other Meetings. If appropriate, assist in identifying and helping to set up meetings with local
development partners relevant to the assignment.
Facilitate Contacts with Partners. Introduce the team to project partners, local government
officials, and other stakeholders, and where applicable and appropriate, prepare and send
out an introduction letter for team‘s arrival and/or anticipated meetings.
Following In-country Work:
USAID/Liberia will undertake the following once the in-country work is completed:
Timely reviews: Provide timely review and approval of the draft/final draft reports.
XII. MISSION CONTACT PERSON
Anna McCrerey, Health Officer, USAID/Liberia will serve as point of contact until July 5th, at
which time Selam Kebrom, Program Officer and Evaluation Team Member will take over.
32 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 33
APPENDIX B. PERSONS CONTACTED
MS YAH ZOLIA MOHSW /Acting Deputy Minister for Planning, Research and
Development
MOMOLU SIRLEAF MOHSW /Head of External AID Coordination Unit
MS JESSIE E. DUNCAN MOHSW /Deputy Minister of Curative Service
MOSES PEWU MOHSW / Deputy Minister of Preventive Service
ESTHER VORDZORGBE Pool Fund
RANDOLPH AUGUSTIN USAID Liberia Health Team Leader
NOE ROKOTONDRAJAONA USAID Liberia President‘s Malaria Initiative Advisor
AUGUSTIN MOBA USAID Liberia
SELAM KEBRON USAID Liberia contact
SOPHIE PARWON USAID Liberia
ANNA MCREREY USAID Liberia
RICHARD BRENAN RBHS COP
ZAIRA ALONZO RBHS DCOP
ROSE MACAULEY RBHS Technical Team Leader
MARION SUBAH RBHS Education & Training Advisor
JOSHUA OFORI RBHS BCC Advisor
BAL RAM BHUL RBHS M&E Dir
TEAH DOEGMAH RBHS BCC P.O.
DAVID FRANKLIN RBHS Mental Health Advisor
MIKE MULBACH RBHS M&E
BEDAR H. FARKAT RBHS
TAREK M. HUSSAIN UNICEF Health Program Coordinator
JOSEPHINE FREEMAN UNICEF MCH
JULIE GARON UNICEF Health Consultant
JESSICA LOWDEN World Learning Project Director
LEONARDO THOMAS Africare
ANTHONY YEAHPALAH Africare
MARY A. TUCKER Africare
ROLAND GASTLOR Africare
JAMES KALLIE Africare
ALOYSIUSNYANDU Africare
34 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
SCOTT VICTOR Africare
DAVID M. MEMBAH EQUIP
GENEVIE NUAH EQUIP
ABRAHAM TOZAY EQUIP
OLIVE TEAH EQUIP
GAYFOR BARNAR EQUIP
LOUDRINA DONKOH EQUIP
VICTOR SUAH EQUIP
KRISTEN CAHILL EQUIP
TEFERI BEYENE MTI
GEORGE KAINE RBHS
JERRY ZANGAR MTI
JULIUS GARBO Cape Mount CHT
EDWARD MASSAQUIN Cape Mount CHT
LAWRENCE MOORE Cape Mount CHT
MATTHEW PAASEWE Cape Mount CHT
ERIC KAPLEE Cape Mount CHT
GEOFFREY GBARTE Cape Mount CHT
THERESA ALPHA Cape Mount CHT
VARLIE SIKAMARA Cape Mount CHT
RAYMOND HOLDER Cape Mount CHT
ABRAHAM WILES Cape Mount CHT
MORRIS LASANMA Cape Mount CHT
WILLIAM PEWU Cape Mount CHT
GARFEE WILLIAMS Bong CHT
GERTRUDE COLE Bong CHT
JESSICA WALKER Bong CHT
RUFUS Bong CHT
NYANDAY DORBOR Medena Clinic
LORETA COLLINS EQUIP
VARNEY FMEREMAN Medena Clinic
ZUANA GRAY Medena Clinic
GOENNA BROWN Medena Clinic
VARNEY GRAY Medena Clinic
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 35
DUALLAU HOWE CHO/Bong
PHIDERALD PRATT UNFPA
HANNAN BESTMAN IMAD
CLEMENT LUGALA WHO
JUAN CASANOVA EU
MOSES MASSAQUOI Clinton foundation
DAVID LOGAN Global Fund
Nicolas Low IRC
Wilson Ballah IRC
Dr. Folaranmi Ogunbowale IRC
Vekeh Donzo IRC
36 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT 37
APPENDIX C. LIBERIA PERFORMANCE BASED FINANCING
(PBF) ASSESSMENT REPORT (FINAL DRAFT, JUNE 2011)
REPUBLIC OF LIBERIA
MINISTRY OF HEALTH & SOCIAL WELFARE
LIBERIA PERFORMANCE BASED FINANCING (PBF)
ASSESSMENT REPORT
(Final draft, June 2011)
38 REBUILDING BASIC HEALTH SERVICES (RBHS): YEAR 2 ASSESSMENT
INTRODUCTION
This report aims to capture the findings of a joint mission of Ministry of Health and Social
Welfare (MOHSW), World Bank, and Rebuilding Basic Health Services (RBHS), which took
place in early May 2011 to assess current functioning of Performance Based Contracting (PBC)
in the context of Liberia‘s post-conflict health reconstruction. The assessment was to lead to
recommendations regarding improved institutional and implementation arrangements for PBC as
well as an operational manual.
The cornerstone of Liberia‘s new, post-conflict national health policy as formulated and
endorsed in 2007 is the rollout of a Basic Package of Health Services (BPHS) to all citizens. This
BPHS is composed of a number of well-proven and affordable health interventions that are to
reach the population through a network of health clinics, health centers, and first-level referral
hospitals all over Liberia. Interventions and required inputs (equipment, drugs and number and
level of staff) have been determined by level of health facility. Based on these inputs all health
facilities can be assessed in an annual accreditation exercise.
While in the past the government was the main provider of health care, next to a number of
faith-based organizations (FBOs), during and after the war international non-governmental
organizations (INGOs) became main providers in an otherwise dilapidating health system.
Against a backdrop of governmental policy to decentralize, it is the vision of the MOHSW that
the county health teams (CHTs) will be responsible for health care provision in their counties.
For the time being, however, it is envisaged that INGOs will play an important role in assisting
the CHTs to take up this responsibility.
At the moment, the rollout of the BPHS takes place through different implementation
mechanisms. All mechanisms may be found in different parts of the country, which means that a
particular county may be covered by more than one mechanism. Broadly, there are currently
three mechanisms, based on a purchaser-provider split model, next to direct government
provision.
These first three mechanisms are governed by contracts between fund holder and implementing
agency. The majority of these contracts is or is meant to be ‗performance based,‘ whereby a
portion of the payment is determined by achieved results. These three mechanisms are:
RBHS
RBHS is a USAID sponsored program, implemented by John Snow Inc (JSI). One of its
components entails contracting INGOs7 to support health care delivery in a number of
countries. The scheme started by mid-2009, and 4 NGOs were contracted to provide support
to 95 health facilities in 6 counties.8 From the start this scheme uses ‗PBC.‘
Pool Fund
The Pool Fund was established in 2009, mainly with funds from DFID and Irish Aid. The Pool
Fund secretariat is based within the MOHSW. By the end of 2009, the Pool Fund contracted
Bomi CHT to provide health care in 20 health facilities, as a pilot on ‗contracting in.‘ By March
2010 the Pool Fund also contracted INGOs for support to the delivery of the BPHS. In total 4
NGOs were contracted to support 87 health facilities in 6 counties. All INGOs partnered with a
7 RBHS also provided a grant to Merci to implement BPHS in 15 facilities in River Gee county; in many
aspects similar to the other contracts, but not formally PBC. 8The contracted INGOs by county are: Africare (Bong, 16 facilities), EQUIP (Nimba, 23 facilities), IRC